Strengthening facility-based immunization service delivery in local government areas at high risk for polio in Northern Nigeria, 2014-2015

Introduction The National Stop Transmission of Polio (NSTOP) program was created in 2012 to support the Polio Eradication Initiative (PEI) in Local Government Areas (LGAs) at high risk for polio in Northern Nigeria. We assessed immunization service delivery prior to the commencement of NSTOP support in 2014 and after one year of implementation in 2015 to measure changes in the implementation of key facility-based Routine Immunization (RI) components. Methods The pre- and post-assessment was conducted in selected health facilities (HFs) in 61 LGAs supported by NSTOP in 5 states. A standardized questionnaire was administered to the LGA and HF immunization staff by trained interviewers on key RI service delivery components. Results At the LGA level, an increase was observed in key components including availability of updated Reach Every Ward (REW) micro-plans with identification of hard to reach settlements (65.6% baseline, 96.8% follow-up, PR = 1.5 (95% CI 3.4 - 69.8), vaccine forecasting (77.1% baseline, 93.5% follow-up, PR =1.2 (95% CI 1.8 - 13.8), and timely delivery of monthly immunization reports (73.8% baseline, 90.2% follow-up; PR =1.2 (95% CI 1.2 - 9.0). At the HF level, there was an increase in percentage of HFs with written supervisory feedback (44.5% baseline, 82.5% follow-up, PR = 1.8 (95% CI 4.7 - 7.3), written stock records (66.5% baseline, 87.9% follow-up, PR = 1.3 (95% CI 2.9 - 4.7) and updated immunization monitoring charts (76.3% baseline, 95.6% follow-up, PR = 1.3 (95% CI 4.6 - 9.9). Conclusion We observed an improvement in key RI service delivery components following implementation of NSTOP program activities in supported LGAs.


Supplement article
Available online at: https://www.panafrican-med-journal.com/content/series/40/1/6/full Strengthening facility-based immunization service delivery in local government areas at high risk for polio in Northern Nigeria, 2014-2015

Introduction
Strengthening facility-based immunization service delivery in Nigeria has consistently required health systems strengthening and extension of its reach to underserved and hard-to-reach populations [1,2]. In 2012, as a component of the Global Emergency Action Plan, Global Polio Eradication Initiative (GPEI) partners were urged to ensure that vaccination coverage increased among underserved populations to eliminate the persistence of Wild Poliovirus (WPV) transmission. Limited facility-based service delivery was a backdrop to the surge in WPV cases and the persistence of transmission in Nigeria among the underserved populations during 2011-2016 [2,3].
In July 2012, the National Stop Transmission of Polio (NSTOP) program was established in Nigeria to support the implementation of the Global Emergency Action Plan in LGAs, which are responsible for immunization service delivery in health facilities (HF). The program is implemented by the National Primary Health Care Development Agency (NPHCDA) in collaboration with the United States Centers for Disease Control and Prevention (CDC), the Nigeria Field Epidemiology and Laboratory Training Program (NFELTP), and the African Field Epidemiology Network (AFENET). It is modeled after the international Stop Transmission of Polio program conducted by the CDC with the World Health Organization (WHO), and UNICEF. NSTOP local officers (NSLOs) were deployed to the LGAs in Northern Nigeria that were assessed as very high-risk for WPV transmission to strengthen HF-based immunization service delivery at LGA level [3][4][5] through i) capacity building for human resources delivering immunization services; ii) improvement in micro-planning, using the Reach Every Ward (REW) (Wards are subdistricts within LGAs) approach, which is aligned with the WHO´s Reach Every District (RED) strategy [5,6] to ensure more infants are reached; iii) improvement in coordination and planning among HF-based immunization service delivery stakeholders, and supportive supervision in health facilities providing immunization services [6,7]; iv) support for the implementation of supplemental immunization activities. The deployment occurred in phases, and the last (3rd) phase of officers were deployed in 2014 across 81 high risk LGAs in six states -Adamawa, Bauchi, Kano, Sokoto, Taraba and Borno. Upon commencement, officers went through modular trainings with post-training field assignments, focused on improving HFbased immunization service delivery.
To assess the impact of NSTOP support on HF-based immunization service delivery implementation in high-risk LGAs, a baseline assessment was conducted prior to the commencement of NSTOP support and a follow-up assessment was conducted one year later. The specific objectives of each assessment were to: 1) assess the availability of key immunization service delivery components at the LGA and HF levels; 2) compare the status of vaccination coverage indicators at baseline and follow-up; 3) identify opportunities for additional improvements in HFbased immunization service delivery.

Study area
We selected 61 phase 3 LGAs supported by NSTOP in 5 states (Adamawa, Bauchi, Kano, Sokoto and Taraba) for the assessment (Figure 1). The 20 phases 3 LGAs in Borno state were not included in the assessment because of security and access constraints.

Study design and sampling
A cross-sectional study was conducted which composed of a baseline assessment in December 2014 and a follow-up assessment in December 2015. Each assessment took a month with field activities lasting for 2 weeks. All the wards in the LGA except those inaccessible due to security issues were assessed. There was a total of 794 wards across 61 LGAs, however only 723 were assessed in baseline and 715 in follow-up. Wards that were not assessed in the baseline were automatically excluded from follow-up assessment. Two HFs were randomly selected from each ward in all the accessible LGAs. In wards with only one HF, that HF was automatically selected and assessed. The selection of HF to be visited in the ward was done through balloting. All HFs in the ward were assigned numbers on pieces of papers and dropped in a box from which one HF was randomly picked by the independent evaluator and visited for the assessment. Same procedure as maintained in follow-up assessment and same LGAs were assessed in both baseline and follow-up.

Participants
LGA respondents were the LGA Immunization Officer (LIO), cold chain officer, and health educator. HF respondents were the HF in-charge (or management coordinator) and the HF-based immunization service delivery focal person.

Data collectors
Data were collected by independent interviewers who were graduates of the Nigerian field epidemiology and laboratory training program with a minimum qualification of Master of Public Health and who could speak the local dialect. They were trained for two days with a one-day field activity exercise for hands-on experience.

Data collection
We used structured interviewer-administered questionnaires that were based on the Expanded Program on Immunization review tool obtained from the WHO website [8]. Using these questionnaires, we collected similar information at the LGA and HF levels about REW micro-plans, the availability of key RI service delivery components, including the availability of updated micro-plans and updated HF vaccination coverage monitoring charts; functionality of available Cold Chain Equipment (CCE) and maintenance of the updated temp monitoring charts; conducting planned immunization sessions in HFs; demand creation activities; and supportive supervision of HFs by the LGA staff including monthly LGA feedback at HFs.

Data sources
Data gathered from verbal responses from the respondents was further verified by visualization of the RI data tools used at the facility before it was documented as available.

Data analysis
Data were analyzed using Epi info™ 7 (2007) and Microsoft Excel™ (2010). Univariate and bivariate analyses were conducted using SPSS version 23 [9] and Microsoft Excel. We calculated the proportion of LGAs and HFs with RI indicators and determined proportion ratios (PR) by dividing the proportion with an indicator in the post-implementation assessment with the proportion in the pre-implementation assessment. We used PR to compare the change in the two proportions while Farrington and Manning´s Score was used to determine 95% Confidence Interval (CI). For LGA-level analysis, data from the same 61 LGAs were analyzed. For health-facility level analysis, due to the absence of a unique identifier for a health facility in the health facility database, we could not separate the health facilities that were included in both baseline and follow-up

Results
Of the 794 wards across 61 LGAs, a total of 884 HFs in 723 wards were assessed at the baseline, and 861 HFs in 715 wards were assessed at follow-up (   )). The proportion of planned, fixed, and outreach sessions conducted in HFs providing immunization services increased from 50.5% at baseline to 64.4% at follow-up; PR= 1.3 (95% CI 1.5 -2.2) and 40.1% at baseline to 60.8 at follow-up; PR = 1.5 (95% CI 1.9 -2.8) respectively, as well as increases in other key components of immunization service delivery at HF level (Table 3).

Discussion
NSTOP support was able to improve the infrastructure necessary to support HF-based immunization service delivery and aid this aspect of polio eradication efforts. There was a significant improvement in some key components of immunization service delivery measured within a year after NSTOP initiated support to states. Key improvements were recorded at follow-up in planning and service delivery, vaccine and stock management, supervision, monitoring and communication for effective immunization service delivery when compared with the baseline. The improvement in the number of personnel who received immunization service delivery training is in line with the NSTOP´s model of regular mentorship and capacity building of immunization service delivery personnel [3] in line with one of the nine transformative investment of the Global Routine Immunization Strategies and Practices to achieving better immunization outcomes [1].
Effective micro-planning for HF-based immunization sessions, a key component of the REW strategy [7], is aimed at maximizing the limited available resources to ensure equitable delivery of immunization services and ensuring that all settlements are reached either through fixed or outreach sessions held at identified sites. These micro-plans are expected to be updated quarterly to ensure that missed and new settlements are captured and that there is equitable access for all children within the facility´s catchment area. The assessment identified an increase in the availability of updated REW micro-plans at both LGA and HF levels though a lot of activities involved in REW update were affected by the irregular release of funds from the state government for the development of these plans. However, most HFs recorded an increase in the number of immunization sessions conducted and a reduction in cancellation of sessions. This finding could be attributed to the technical support, mentorship, and improved supportive supervision provided for these facilities by NSLOs which was a key deliverable in the terms of reference. Additionally, the irregular release of funds for immunization services to HFs could have affected the expected improvement in the conduct of outreach sessions where transportation logistics have been identified as being critical. The reported insecurity challenges could have also attributed to the interruption of immunization services in HF and at outreach sites.
Reported stock-outs of some vaccines in HFs could be attributed to the pull system of vaccine delivery, which requires a visit from HF staff to the LGA, and a visit from LGA staff to the State, to collect vaccines. The pull system is often used in health facilities that do not have their own CCE, often collecting vaccines from the LGA on the day of the immunization session. A transportation or other logistical problems on the day of the immunization session could result in stock-out of vaccines [10]. Cold chain monitoring and maintenance improved among facilities that had CCE; however, the availability of CCE was not uniform across all HFs.
There was improvement in monitoring of data for action and communication for HF-based immunization service delivery. The availability of vaccination coverage monitoring chart that captures key immunization service delivery indicators regularly updated and routinely monitored in line with the immunization accountability framework indicators in the strategic plan [11] are critical for data-driven decisionmaking. NSLOs routinely supervise health facilities and mentor them on the use of updated vaccination coverage monitoring charts and tracking of the indicators on the charts to identify facilities not meeting the set targets which are then prioritized for follow-up supportive supervision.
Improvements were noted in the availability of supervisory plans, the proportion of the supervisory visits conducted among those planned, the availability of completed supervisory checklists and written supervisor feedbacks that identified follow-up actions. Although partner organization staff conduct most visits, LGA teams are usually paired with partners to conduct supportive supervisory visits to HFs to identify best practices and prioritize those HFs with challenges for follow-up actions [6].
The availability of monthly and annual reports also improved in the followup assessment from baseline, including feedback from the state and LGA to HFs. This can possibly be attributed to the mentorship provided at all levels, as well as the increased capacity of personnel on writing reports [12,13].
The availability of social mobilization and communication plans at both baseline and follow-up including the involvement and functionality of Ward Development Committees (WDCs)/Village Development Committees (VDCs) in immunization services at some facilities can be attributed to technical support and frequent community engagement activities conduct during supervision. This was identified as a critical area that needed support to raise community awareness, create demand, and clear misconceptions about immunization. NSTOP did not provide funding of WDCs/VDCs but technically facilitated and supported their meetings.

Limitations
This study had some limitations; some HFs included in the baseline assessment within the same LGA were not the same HFs included in the follow-up assessment, and different numbers of HFs were assessed at each point in time. However, we believe that findings can be generalized to what is applicable in all HFs in the LGAs. Also, security challenges did not allow for a full assessment of all HFs due to inaccessibility in some areas. Lastly, in the before and after design, we did not include any nonintervention areas that would have allowed us to assess any effect of secular trends on program performance.

Conclusion
This assessment showed an improvement in some of the key components of HF-based service delivery, after a one year of NSTOP support to the states. Key areas that provided opportunities for additional support to strengthen HF-based service delivery, especially in the measles elimination efforts and the control of other VPDs were also identified. These included tailored support on vaccine management and cold chain logistics, communication and social mobilization for demand generation for childhood immunization, optimization of the quality of supportive supervision for immunization services, regular capacity building for health workers at all levels, as well as support for the conduct of outreach sessions to ensure that HF-based services reach the unreached communities. Therefore, we recommend that LGAs (a) develop vaccine delivery mechanisms that will ensure a regular and adequate supply of vaccines and other logistics needed to conduct sessions, (b) strengthen social mobilization activities to forestall interruption of HF-based services, and (c) train personnel on preventive maintenance of available CCE. We also recommend that communication and demand generation activities to increase uptake of immunization should be prioritized and adequately